147

Hypospadias

Warren T. Snodgrass; Nicol Corbin Bush

Questions

1.A 6-month-old male presents for evaluation of subcoronal hypospadias. During physical examination, the left testicle is palpated in the groin but cannot be manipulated into the scrotum. The next step is to:

a.re-examine in 6 months to allow for testicular descent.

b.perform ultrasonography to rule out testicular retraction.

c.obtain a karyotype.

d.schedule hypospadias repair now, and orchiopexy in 6 months.

e.schedule orchiopexy now, with hypospadias repair in 6 months.

2.During a proximal penile shaft hypospadias repair, a catheter cannot be passed into the bladder. The most likely cause is:

a.a false passage in the urethra.

b.an enlarged utricle.

c.partial urethral duplication ending in a blind pouch.

d.an elevated bladder neck.

e.proximal urethral stricture.

3.A 6-month-old infant without other known medical problems is referred for scrotal hypospadias. He is also found to have ventral penile curvature, a deep scrotal cleft, and penoscrotal transposition, but both testes are in the scrotum. The next step is:

a.proceed with surgery.

b.obtain a karyotype

c.order a voiding cystourethrogram (VCUG) to visualize the utricle.

d.obtain renal sonography.

e.schedule testicular ultrasonography.

4.A patient with penoscrotal hypospadias has ventral curvature of nearly 90

degrees preoperatively. After the penis is degloved and dartos tissues released, artificial erection shows the curvature has diminished to less than 30 degrees. The best next step is:

a.transect the urethral plate.

b.perform dermal grafting of the corpora cavernosa at the point of greatest bending.

c.proceed with urethroplasty.

d.perform a midline dorsal plication.

e.perform midline dorsal plication and ventral dermal corporal grafting.

5.A 6-month-old male is referred for hypospadias. On examination he is found to have a dorsally hooded prepuce, ventral penile curvature, a glanular meatus, and a normal scrotum. The parents should be informed that straightening the penile curvature most likely will require:

a.only skin degloving and ventral dartos dissection.

b.multiple dorsal midline plications.

c.ventral corporal grafting.

d.transection of the urethra.

e.single dorsal plication and ventral corporal graft.

6.A 6-week-old infant is evaluated after newborn circumcision. The primary care physician expresses concern for a "bad circ." On examination the meatus is coronal and the glans wings are separated. There is no redundant shaft skin following the circumcision except in the ventral midline near the meatus. The family should be informed that:

a.these findings indicate urethral injury during circumcision.

b.urethroplasty will best be performed using a ventral preputial skin flap.

c.circumcision most likely has affected vascularity to the redundant ventral skin, and so urethroplasty will best be done using the skin as a graft.

d.following circumcision, urethroplasty will require buccal graft from the lower lip.

e.their infant has a hypospadias variant.

7.The parents of a 6-month-old male with subcoronal hypospadias request foreskin reconstruction rather than circumcision. The parents should be informed that:

a.preoperative testosterone therapy to enlarge the foreskin is recommended.

b.complication rates are significantly greater with prepucioplasty.

c.they should not retract the foreskin in the first 6 weeks after surgery.

d.a gentle compression dressing should be used to minimize preputial edema after surgery.

e.the foreskin most likely will be needed for urethroplasty and so circumcision will likely be necessary.

8.Each of the following is thought to reduce the likelihood for fistula development after hypospadias surgery EXCEPT:

a.subepithelial suturing of the neourethra.

b.2-layer closure of the neourethra.

c.monofilament sutures.

d.approximation of the corpus spongiosum over the neourethra.

e.placement of a dartos flap over the neourethra.

9.A mother reports her 7-year-old child who had a penoscrotal tubularized incised plate (TIP) hypospadias repair took longer to void than a playmate during a sleepover. He does not strain to urinate and has had no urinary tract infections (UTIs). Uroflowmetry shows a peak flow rate of 8 mL/sec with a plateau-shaped curve. The next step is to:

a.reassure that the flow rate is within the normal range.

b.recommend VCUG to rule out stricture.

c.perform urethral dilation.

d.schedule for flap reoperative urethroplasty.

e.advise buccal inlay reoperative urethroplasty.

.An 8-year-old had distal hypospadias repair as an infant. Initially after surgery he was thought to have a normal urinary stream, although the parents only rarely observed urination because he used diapers. During the past year the parents think his stream has slowed and notice he seems to have to "push" to empty his bladder. Examination reveals a faint white discoloration around the meatus. Best management includes:

a.intraoperative biopsy with frozen section.

b.meatotomy for meatal stenosis.

c.flip-flap reoperative urethroplasty.

d.topical steroids for 6 weeks.

e.excision of the distal urethra with two-stage buccal graft urethroplasty.

.A 1-year-old boy had a subcoronal hypospadias repair 6 months ago but has a 2-mm fistula at the site of the original meatus. Distance from the fistula to the neomeatus is approximately 4 mm, and the glans wings still appear approximated. The best treatment of the fistula is:

a.midline incision through the neomeatus to the fistula with reoperative distal urethroplasty.

b.rotational skin flap fistula closure.

c.fistula closure covered with a ventral dartos barrier flap.

d.inlay buccal graft urethroplasty.

e.dilation of the meatus for stenosis.

.A 10-year-old boy presents with midshaft hypospadias persistent after seven operations on his penis. He appears to have ventral curvature greater than 30 degrees and has been circumcised. There is visible scarring between the meatus and the glans, and the scrotum is riding high on the penile shaft to near the meatus. The best procedure is:

a.TIP reoperation.

b.flip-flap reoperative urethroplasty.

c.onlay flap reoperative urethroplasty.

d.inlay buccal graft urethroplasty.

e.two-stage buccal graft urethroplasty.

.A 6-year-old boy who had a tubularized preputial flap hypospadias repair as an infant presents with a slow urinary stream and stranguria worsening over the past year. Physical examination is unremarkable, but the peak flow is

3 mL/sec with a postvoid residual of 75 mL. At surgery cystoscopy shows a 5- mm stricture near the original meatus. This stricture is best corrected by:

a.urethral dilation.

b.direct vision internal urethrotomy (DIVU).

c.DIVU with urethral dilations for 3 months.

d.inlay buccal urethroplasty.

e.staged buccal graft reoperation.

.A 9-year-old prepubertal boy has failed multiple operations for penoscrotal hypospadias. Examination shows a distal shaft meatus, persistent ventral curvature, and a flat ventral glans. During planned two-stage buccal graft reoperation, it becomes apparent the entire neourethra will have to be excised back to the penoscrotal junction. The best plan for first-stage grafting is to:

a.use cheek tissue on the penile shaft and maintain the remnant prepuce in the glans.

b.use cheek tissue to graft the entire defect.

c.use lower lip tissue for the entire graft.

d.use lip tissue on the penile shaft and cheek tissue within the glans.

e.use ventral penile shaft skin to graft the entire defect.

.An infant with distal shaft hypospadias has a narrow, flat appearance to the urethral plate. Artificial erection after degloving shows the penis to be straight. The best option for urethroplasty is:

a.meatoplasty and glansplasty (MAGPI).

b.TIP.

c.flip-flap with V incision meatoplasty.

d.to incise the urethra to the midshaft and perform onlay preputial flap repair.

e.to inlay buccal graft from the lip and then tubularize the urethral plate.

.Parents report that their 1-year-old boy seems to be having difficulty urinating 3 months after TIP repair for coronal hypospadias. They have observed the stream once or twice and thought it looked thin. On examination the glans looks entirely normal, except the meatus appears small. You attempt to calibrate the meatus, and an 8-Fr sound will not pass. The most likely cause for this complication is:

a.Balanitis xerotica obliterans (BXO).

b.ischemia of the neomeatus.

c.postoperative edema of the meatus.

d.suturing the urethral plate too far distally.

e.compression from the glans wings closure.

.Parents report that their 1-year-old boy seems to be voiding without any problems 6 months after TIP repair for coronal hypospadias, although they have not seen the actual urinary stream because he is still in diapers. On examination you observe that the meatus appears small. The next step is:

a.calibrate the meatus.

b.obtain VCUG.

c.schedule examination under anesthesia and meatotomy

d.recommend reoperative urethroplasty, using either a ventral flip-flap if possible, or inlay buccal grafting from the lip.

e.begin daily urethral dilations for 6 weeks.

.A surgeon chooses Koyanagi flap repair for a child with scrotal hypospadias and ventral curvature who also needs rotational flap scrotoplasty for penoscrotal transposition. The surgeon should:

a.delay scrotoplasty for 6 months to protect skin flap vascularity.

b.perform urethroplasty and scrotoplasty in a single operation.

c.straighten ventral curvature and perform scrotoplasty in the first operation and delay urethroplasty for 6 months.

d.straighten ventral curvature and perform urethroplasty and scrotoplasty at a second procedure in 6 months.

e.correct ventral curvature and perform scrotoplasty simultaneously, and stage the urethroplasty.

.A 19-month-old male presents for evaluation of scrotal hypospadias. The mother has noted that his pupils seem enlarged, and she is concerned he might have developmental delay. He is crying during examination, hindering inspection of his eyes. He has scrotal hypospadias with a deep scrotal cleft, but both testes are in the scrotum. His evaluation before surgery should include:

a.renal sonogram.

b.testicular sonogram.

c.VCUG.

d.testosterone/dihydrotestosterone ratio.

e.measurement of Müllerian inhibition hormone.

.A 10-year-old boy had hypospadias reoperation 1 year ago that included a tunica vaginalis barrier flap over the neourethra harvested from the right testicle. He reports no problems voiding, but with erection the penis is pulled to the right side. The next step is to:

a.reassure him the tension on his penis will resolve at puberty.

b.make a small scrotal incision and transect the tunica vaginalis flap.

c.make a midline penile incision and excise the tunica vaginalis flap.

d.create a tunica vaginalis flap from the left testis to evenly distribute the tension on the penis during erection.

e.instruct the patient to pull the penis toward the left during erection to relax contracted tissues.

.A 14-year-old undergoes a first-stage buccal graft reoperation that involves grafting along the entire penile shaft. The next morning he is found to have visible hematoma under the shaft skin. The next step is:

a.return immediately to the operating room to evacuate the hematoma.

b.apply a compression dressing over the penis and scrotum.

c.check coagulation profiles for bleeding diathesis.

d.observe with continued bed rest.

e.evacuate the hematoma and regraft the penile shaft.

.The mother of a patient with coronal hypospadias is pregnant again. She asks, if the child is a male, is he likely to also have hypospadias? She should be told that: